Since its emergence in December 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19) has spread rapidly [
]. COVID-19 has had a broad effect on the general population, has changed our current way of living, and changed patient management in hospitals. All services had to adapt to the changes, including the implementation of personal protective equipment (PPE) to avoid cross-contamination and the spread of infection [
- Zhu H.
- Wei L.
- Niu P.
The novel coronavirus outbreak in Wuhan, China.
Glob Health Res Policy. 2020; 5: 6
]. Before COVID-19, healthcare workers based in high-risk environments, such as intensive care units (ICUs), wore gloves and gowns as part of their PPE, and followed continuous strict hand hygiene when taking endotracheal secretion (ETS) samples and aseptic precautions for blood culture collection. Hand hygiene is known to be an effective method to reduce the transmission of infection [
- Gordon C.
- Thompson A.
Use of personal protective equipment during the COVID-19 pandemic.
Br J Nurs. 2020; 29: 748-752
]. Since COVID-19, various PPE has been required, including surgical face masks, gloves, gowns and face shields, to prevent the spread of SARS-CoV-2. PPE guidance has been variable throughout this time on our unit; however, the use of surgical face masks for both staff and visitors in patient settings has been consistent throughout the post-COVID era. The use of surgical face masks was not mandatory on our unit in the pre-COVID era.
Managing and preventing outbreaks of Gram-negative infections in UK neonatal units [NHS networks]. 2012
The impact of COVID-19 on neonates has not been substantial. In the UK, deliveries of extremely preterm (22–26 weeks), preterm (27–32 weeks) and moderately preterm (33–37 weeks) infants have not changed significantly over the last 3 years. The UK national cohort study reported that transmission of COVID-19 infection from infected mothers to neonates was uncommon, and a recent review showed that the affected infants were either asymptomatic or only had mild symptoms [
]. The effect of SARS-CoV-2 on neonates is clearly mild and the use of PPE protects neonates from the virus [
- Athiraman N.K.
- Patience A.
- Onwuneme C.
- Zalewski S.
- Skeath T.
Impact of COVID-19 on maternity and neonatal services – three year-on-year review data from the North East of England.
Acta Paediatr. 2022; 111: 1039-1041
]. It is unclear whether the changes to PPE for patient encounters reduces the rates of other infections in neonates. Neonatal infection remains the main cause of mortality and morbidity [
- Tong W.Y.
- Yung C.F.
- Chiew L.C.
- Chew S.B.
- Ang L.D.
- Thoon K.C.
- et al.
Universal face masking reduces respiratory viral infections among inpatient very-low-birthweight neonatal infants.
Clin Infect Dis. 2020; 71: 2958-2961
- Stoll B.J.
- Hansen N.I.
- Bell E.F.
- Shankaran S.
- Laptook A.R.
- Walsh M.C.
- et al.
Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network.
Pediatrics. 2010; 126: 443-456
]. As such, we aimed to determine whether the use of face masks by staff reduced the rate of positive cultures in neonates in our neonatal ICU during the COVID-19 pandemic.
- Wynn J.L.
Defining neonatal sepsis.
Curr Opin Pediatr. 2016; 28: 135-140
A retrospective review of patient records was undertaken. Data were collected from local microbiology databases and Badger net records. All blood and ETS cultures were taken in the neonatal ICU at Royal Victoria Infirmary, Newcastle upon Tyne, UK between March 2018 and March 2021. The ‘pre-COVID’ period was defined as March 2018–March 2020, and the ‘post-COVID’ period was defined as March 2020–March 2021. Fisher's exact test was used to compare proportions. Graphpad Prism Version 9 was used for data analysis.
The results showed that the mean weight of neonates admitted in the pre-COVID period was 2474 g (range 440–5320 g), compared with 2604 g (range 400–5535 g) in the post-COVID period. The mean gestation in the pre-COVID period was 34+5 weeks (range 22–42 weeks), compared with 35+1 weeks (range 22–42 weeks) in the post-COVID period. The total number of positive blood cultures was 45 in 2018–2019, 77 in 2019–2020 and 60 in 2020–2021. The total number of positive ETS samples was 95 in 2018–2019, 156 in 2019–2020 and 99 in 2020–2021. The number of septic episodes requiring blood cultures was similar for each year: 2018–2019, N=838; 2019–2020, N=838; and 2020–2021, N=831. The same was found for the total number of ETS samples collected (N=224, 346 and 279, respectively). The percentage of positive blood cultures was 7.28% in the pre-COVID period and 7.22% in the post-COVID period; this difference was not significant (P=0.99). The percentage of positive ETS samples was 44.04% in the pre-COVID period and 35.48% in the post-COVID period; this represented a significant reduction in positive ETS samples of 8.56% (P=0.0174) (Figure 1).
There was a significant reduction in culture-positive ETS samples during the post-COVID period. The gestations and birth weights of neonates admitted to our unit were similar for the pre- and post-COVID periods. The proportion of septic episodes that required a blood culture to be taken was also similar for the pre- and post-COVID periods. Therefore, the demographics and acuity of neonates on our unit are also likely to be similar between the two periods. Given this population similarity, we found no significant difference in the proportion of positive blood cultures in the pre- and post-COVID periods, but there was a significant reduction in the proportion of positive respiratory cultures in the post-COVID era.
We conclude that the use of face masks reduces the number of positive respiratory cultures, and therefore is likely to correlate with a reduced number of neonatal respiratory infections on our unit. Our data support the continued use of face masks when managing high-acuity neonates, with the aim of reducing the rate of respiratory infections. We recognise there were many variables other than PPE guidance during this time, and therefore it is important to replicate this study, in a controlled manner rather than an observational manner, at multi-regional or national level to identify experiences and changes in infection rates. This would enable the neonatal community to recommend additions to current infection control policies.
The authors wish to thank all the staff on the neonatal ICU at the Royal Victoria Hospital, Newcastle upon Tyne for all their help with sample collection.
Conflict of interest statement
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Dr Thomas Altmann and Dr Shaden Zuhairy jointly analysed the data and wrote this paper. They are joint first authors. Dr Manjusha Narayanan provided the microbiological data and advised on study design. Dr Naveen Athiraman conceived the original idea and supervised the project.
- The novel coronavirus outbreak in Wuhan, China.Glob Health Res Policy. 2020; 5: 6
- Use of personal protective equipment during the COVID-19 pandemic.Br J Nurs. 2020; 29: 748-752
- Managing and preventing outbreaks of Gram-negative infections in UK neonatal units [NHS networks]. 2012 (Available at:)https://www.networks.nhs.uk/nhs-networks/southern-west-midlands-newborn-network/documents/NNU_GNB_outbreaks_Anthony_et_al1.pdf
- Impact of COVID-19 on maternity and neonatal services – three year-on-year review data from the North East of England.Acta Paediatr. 2022; 111: 1039-1041
- Universal face masking reduces respiratory viral infections among inpatient very-low-birthweight neonatal infants.Clin Infect Dis. 2020; 71: 2958-2961
- Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network.Pediatrics. 2010; 126: 443-456
- Defining neonatal sepsis.Curr Opin Pediatr. 2016; 28: 135-140
Published online: May 12, 2023
Accepted: April 20, 2023
Received: April 20, 2023
Publication stageIn Press Journal Pre-Proof
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